Every finding on record at Kauai Hospice, Inc.

Based on record review and interview, the provider failed to maintain a system of communication, specifically [electronic] health record (EHR) documentation, in accordance with the providers own policies and procedures, to ensure the interdisciplinary group (IDG) was able to direct and coordinate the care and services provided. This was evidenced by Nursing Visit Records documented from 3-12 days after the visit had actually been completed, for 2 of 14 active patients (Patient 11 and 19) sampled. As a result of this deficient practice, members of the IDG did not readily have access to the most current information necessary to care for these patients. --- Findings include: 1. Patient (P)11 is an 87-year-old male with an election of hospice care (EOHC) date of 11/22/22. During a review of his EHR, several Nursing Visit Records (NVR) were noted to have been documented well after the visits had been completed. The following demonstrates a pattern of late charting by Registered Nurse (RN)1: 08/29/23 Nurse Visit documented on 09/05/23; 09/05/23 Nurse Visit documented on 09/17/23; 09/12/23 Nurse Visit documented on 09/17/23; 09/26/23 Nurse Visit documented on 10/01/23; 10/18/23 Nurse Visit documented on 10/29/23; 10/24/23 Nurse Visit documented on 10/29/23; 11/14/23 Nurse Visit documented on 11/18/23; 11/21/23 Nurse Visit documented on 11/28/23; 11/28/23 Nurse Visit documented on 12/04/23. In addition, a Nurse Visit completed by RN2 on 08/04/23 was documented on 08/07/23. On 12/14/23 at 03:04 PM, an interview was done with the Director of Nursing (DON) in the Conference Room. The DON confirmed that there should be no more than one day between a visit date and the date it is documented. 2. P19 is a 12-year-old male with an EOHC date of 11/10/23. During a review of his EHR, several NVRs were noted to have been documented well after the visits had been completed. The following details a pattern of late charting by Registered Nurse (RN)1: 11/16/23 Nurse Visit documented on 11/27/23; 11/20/23 Nurse Visit documented on 11/27/23; 11/22/23 Nurse Visit documented on 11/27/23; 12/06/23 Nurse Visit documented on 12/10/23. In addition to the late charting, it was noted that there were two On Call Nursing Records documented between the 11/16/23, 11/20/23, and 11/22/23 visits and the documentation of those visits on 11/27/23. On 11/25/23 and 11/26/23, staff responded to and coordinated care for P19 without having access to clinical notes and assessments from the prior three visits made by RN1. A review of the providers Policy and Procedure titled Clinical/Service Data Collection, last revised October 2015 noted the following: ";Entries in to the clinical service record will be made on the day care/service is provided to the patient."